APPLICATION FOR EMPLOYMENT
PELHAM POLICE DEPARTMENT
FAILURE TO FOLLOW ANY INSTRUCTIONS PROVIDED
WILL RESULT IN AUTOMATIC DISQUALIFICATION
IMPORTANT: READ CAREFULLY
INSTRUCTIONAL INFORMATION SHEET
This sheet has been prepared for your aid in executing the application for employment
with the Pelham Police Department. If there are questions which are not applicable to
you, please indicate this fact by the notation “N/A” in the appropriate space.
If additional space is needed for any section or question on the application, or if you wish
to furnish additional information, attach sheets of the same size as this application, follow
the same format as on the application, and number answers to correspond to the
questions.
The application must be clear and legible; abbreviations are not acceptable. It is
mandatory that all applications be typewritten. Handwritten applications will not be
accepted.
CERTIFICATIONS AND TRANSCRIPTS
Do not attach copies of certificates and transcripts to this application.
EFFECTS OF NONDISCLOSURE
In order to qualify to take the Police Officer Entrance Examination, prospective
applicants must fully complete all items on the Police Department Application Form.
Failure to comply with this requirement will automatically disqualify you from taking the
Entrance Examination.
A false answer to a question in the employment application may be grounds for not
employing you, or for dismissing you after you begin work. All statements are subject to
investigation, including a check of your fingerprints, police records, academic records
and former employers. All information you give will be considered in reviewing your
statement.
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RETURN PROCEDURE
Completed applications will be accepted by postal mail or hand delivery.
The mailing address is:
Pelham Police Department
Attn: Recruiting and Employment
32 Philip Davis St., Pelham, AL 35124
Hand delivered applications will be accepted between the hours of 8:00 A.M. – 5:00 P.M.,
Monday through Friday only, at the Police and Court Building located at 32 Philip Davis St.
PURPOSE AND USE
The principle purpose of this employment application is to collect information needed to
determine qualifications, suitability and the availability of the applicants for employment
with the Pelham Police Department. All or part of your completed application form may
be disclosed outside the Pelham Police Department to:
1. Pelham Police Department investigators to determine your suitability for
employment with the Pelham Police Department.
2. Federal, State or other agencies to create other personnel records after your
employment.
3. Appropriate Federal, State or local law enforcement agencies charged with the
responsibility of investigating a violation or potential violation of the law.
4. Appropriate Federal, State or local agencies maintaining records on you to obtain
information relevant to an agency decision about you.
5. City of Pelham officials involved with internal personnel management functions.
APPLICANT AFFIDAVIT OF ALABAMA P.O.S.T. CERTIFICATION AND
BASIC LAW ENFORCEMENT OVERALL COURSE GRADE.
1. Information provided on the applicant affidavit Alabama P.O.S.T. Certification
section is critical.
2. The overall course average grade achieved upon the completion of an Alabama
P.O.S.T. approved Police Academy shall serve as the applicant’s entrance
examination test score.
3. The overall course average grade shall further determine the applicant’s eligibility
and position on the list of eligible candidates for the position of Police Officer.
4. Applicant affidavit of Alabama P.O.S.T. Certification must be completed in full.
Failure to complete this form or any part of the application shall be considered a
disqualification and the application will not be processed.
PLEASE DETACH INSTRUCTION SHEETS BEFORE SUBMITTING YOUR
APPLICATION.
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APPLICATION FOR EMPLOYMENT
PELHAM POLICE DEPARTMENT
Police Officer
Communications Operator
Clerk
I. PERSONAL HISTORY
1. Name if Full (Last, First, Middle)
2. List all other names you have used including nicknames; if female, furnish
maiden name. If you ever used any surnames other than your true name, during
what period and under what circumstances were these names used?
3. Date of Birth: MM-DD-YYYY
4. Place of Birth:
5. Age:
M
6. Sex:
8. (a) Marital Status:
F
7. SSN#:
(b) Spouse’s Full Name:
9. Citizenship:
(a) Present citizenship (country)
(b) Citizenship acquired by
Birth
Naturalization/Naturalization Certificate #
(c) Date and Place Naturalized
Marriage
10. Driver’s License Number and State:
THE CITY OF PELHAM IS AN EQUAL OPPORTUNITY EMPLOYER
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II. RESIDENCES
Current Address:
Street Address:
City:
State:
Home #:
Zip:
Cell #:
Work Phone #:
Email Address:
NOTE: POST OFFICE BOXES ARE NOT ACCEPTABLE ADDRESSES
ACTUAL PLACES OF RESIDENCE FOR THE PAST 10 YEARS
Any applicant who has been out of high school for more than 10 years must include
addresses while at school and in the military. For college on-campus residence, give
dorm name, city and state. If residences in military service cannot be shown as street
addresses, indicate complete military unit designation and location by city, state and
country.
From / To
Month/Yr.
Month/Yr.
Street Address
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City
State
III. EDUCATION
1. High School:
Address:
Years Attended:
Year Graduated:
GED:
Year Obtained:
2. College or University:
Name of College:
Address, City and State:
Major:
Minor:
Years Attended:
Degree Received:
GPA:
3. Specialized Schools:
Name of School
Study or Specialization
Address, City and State
Dates Attended
Graduate
Yes
No
Yes
No
4. Were you ever dismissed from a school, or was any disciplinary action ever taken
against you during your scholastic career?
Yes
No
School
Date
Action
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IV. EMPLOYMENT HISTORY
Note: List last position first. Include chronological history of employment starting with
current or most recent position. Account for all periods including casual employment and
all periods of employment. Be sure to include military experience, if applicable.
Name and Address of Employer’s Organization
Full
Salary/Earnings $
From / To
time
Part time
per
Exact Title of Your Position
Dates Employed
Name of Immediate Supervisor
Reason for Leaving
Description of Work. Describe Your Specific
Duties.
Name and Address of Employer’s Organization
Full
Salary/Earnings $
From / To
time
Part time
per
Exact Title of Your Position
Dates Employed
Name of Immediate Supervisor
Reason for Leaving
Description of Work. Describe Your Specific
Duties.
Name and Address of Employer’s Organization
Full
Salary/Earnings $
Exact Title of Your Position
Dates Employed
From / To
time
Part time
per
Name of Immediate Supervisor
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Reason for Leaving
Description of Work. Describe Your Specific
Duties.
Name and Address of Employer’s Organization
Full
Salary/Earnings $
Dates Employed
From / To
time
Part time
per
Exact Title of Your Position
Name of Immediate Supervisor
Reason for Leaving
Description of Work. Describe Your Specific
Duties.
Have you ever been dismissed or asked to resign from any employment or position you
have held:
Yes
No. If your answer is “Yes”, set forth your explanations on
an attached sheet indicating the name of the company, your dates of employment and the
reason(s) for your dismissal/resignation.
V. MILITARY RECORD
1. Have you ever served in the Armed Forces of the United States?
Yes
2. Branch of Military Service
3. Type of Discharge
4. Date of Active Duty From
to
5. Service Number
6. Member of the Reserve
Yes
No
7. Branch of Service (Reserve)
8. National Guard
Present
Former
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None
No
9. If you attend drills, meetings or camps, give the name of the unit and location
VI. REFERENCES AND SOCIAL ACQUAINTANCES
Give three references (not relatives or present employers, fellow employees or school
teachers, who are responsible adults of reputable standing in their communities, such as
property owner, business or professional men or women including your physician, if you
have one, who have known you well for at least five years, preferable those who have
known you during the past five years. If retired, give former occupation.
REFERENCES
Complete Name:
Home Address:
Business Address:
Home Phone Number:
Business Phone:
Years Acquainted:
Occupation:
Complete Name:
Home Address:
Business Address:
Home Phone Number:
Business Phone:
Years Acquainted:
Occupation:
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Complete Name:
Home Address:
Business Address:
Home Phone Number:
Business Phone:
Years Acquainted:
Occupation:
SOCIAL ACQUAINTANCES
Complete Name:
Home Address:
Business Address:
Home Phone Number:
Business Phone:
Years Acquainted:
Occupation:
Complete Name:
Home Address:
Business Address:
Home Phone Number:
Business Phone:
Years Acquainted:
Occupation:
Complete Name:
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Home Address:
Business Address:
Home Phone Number:
Business Phone:
Years Acquainted:
Occupation:
VII. ORGANIZATIONAL MEMBERSHIP
Are you now, or have you ever been a member of any club, society or organization?
Yes
No. If yes, list below. Do not abbreviate.
Name:
City/State:
Former:
Present:
Activity:
Name:
City/State:
Former:
Present:
Activity:
Name:
City/State:
Former:
Present:
Activity:
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VIII. COURT RECORD
Have you ever been arrested or charged with any violation, including traffic, but
excluding parking tickets?
Yes
No. To your knowledge, has any member
of your immediate family ever been arrested for other than traffic violations?
Yes
No. If so, list all such matters even if not formally charged or no court
appearance, or found guilty, or matter settled by payment of fine or forfeiture of
collateral.
Court Record
Date:
Place and Department:
Charge(s):
Disposition:
Details:
Date:
Place and Department:
Charge(s):
Disposition:
Details:
Relative’s Name:
Place and Department:
Date/Charges:
Disposition:
Details:
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Have you ever been a plaintiff or defendant in a court action?
Yes
No
If so, give date, place, court, names of parties involved, nature of action and final
disposition:
IX. FINANCIAL STATUS
1. Do you have any sources of income other than your salary or that of your spouse?
Yes
No Specify each with amount.
2. Have you ever been in or petitioned for bankruptcy?
Yes
answer is Yes, give particulars, including court and date(s).
No If your
3. Have you ever been served or involved in a civil action for garnishment of wage
or property?
Yes
No If your answer is Yes, give particulars,
including court and date(s):
X. RELATIVES EMPLOYED BY THE CITY OF PELHAM
List the complete names of any relatives (including in-laws) who are employed by the
City of Pelham.
Complete Name:
Relation:
Department:
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Complete Name:
Relation:
Department:
XI. FRIENDS/ACQUAINTANCES EMPLOYED BY THE CITY OF PELHAM
1. Complete Name:
Department:
2. Complete Name:
Department:
3. Complete Name:
Department:
XII. PHYSICAL DATA
Height:
Weight:
XIII. PERSONAL DECLARATIONS
1. Do you use intoxicants?
Yes
No If so, to what extent?
2. Do you use, or have you ever used items such as marijuana, hashish, cocaine,
LSD, amphetamines, heroin, or drugs of a similar nature?
Yes
No
3. If answers to Question 2 above are Yes complete the following items for each
drug used.
a. Drug:
b. How taken:
c. Circumstances:
d. First time used:
e. Last time used:
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4. List the names of Federal, State and local law enforcement agencies to which you
have applied for employment.
5. If, to your knowledge, any of the above agencies have conducted an investigation
of you indicate the name of the agency and the approximate date of investigation.
6. Are you now, or have you ever been a member of any foreign or domestic
organization, association, movement, group or combination of persons which is
totalitarian, fascist, communist, or subversive, or which has adopted, or shown a
policy of advocating or approving the commission of acts of violence to deny
other persons their rights under the Constitution of the United States, or which
seeks to alter the form of Government of the U.S. by unconstitutional means?
Yes
No. If answer is Yes to any of these items explain fully.
7. An investigation will be conducted of all information listed in this application.
Because of this, are you aware of any information about yourself or any person
with whom you are, or have been closely associated with might tend to reflect
unfavorably on your reputation, morals, character, ability or loyalty?
Yes
No. If Yes, please give your version of this/these incident(s).
8. Do you understand all prospective Pelham Police Department employees will be
required to submit to a urinalysis for drugs of abuse prior to employment?
Yes
No
IX. AVAILABILITY OF APPLICANT
1. Have you previously submitted an application for employment with the
Pelham Police Department?
Yes
No. If so give date MM-DD-YYYY
2. Earliest date available for employment? MM-DD-YYYY
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3. How much notice to report do you need? _____________________________
4. I understand that appointment to support position (communications officer or
clerk) does not assure me of being offered a Police Officer appointment in the
future, even if I meet the basic requirements of this position.
Yes
No
XV. FOREIGN LANAGUAGE
1. List any foreign language’s you speak fluently.
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POLYGRAPH REQUIREMENT
ATTENTION – THIS STATEMENT MUST BE SIGNED
I understand that I will be requested to submit to a Polygraph examination during the
processing of my application and, if hired, subsequent to employment, to assist in
determining my suitability for employment or to resolve issues directly related to my
employment.
I understand that all appointments are probationary for a period of one year during which
I must demonstrate my fitness for continued employment by the Pelham Police
Department. I also understand that, in many parts of the Police Department, it is
necessary to establish regular evening and midnight shifts in view of which I must be
completely available for such assignments. I further understand that any appointment
tendered me will be contingent upon the results of a complete character and fitness
investigation, and I am aware that willfully withholding information or making false
statements on this application will be basis for dismissal from the Pelham Police
Department. I agree to these conditions and I hereby certify that all statements made by
me on this application are true and complete to the best of my knowledge.
___________________________________
Signature of Applicant
Date
(Sign as usually written. Do not use
nickname)
MM-DD-YYYY
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NECESSARY SPECIAL REQUIREMENTS
ATTENTION – THIS STATEMENT MUST BE SIGNED
Within six (6) months of date of hire, employee must establish primary residence within a
thirty-five (35) mile radius from Pelham City Hall, subject to approval of the Chief of Police.
In order to maintain and continue employment as a sworn police officer for the City of
Pelham Police Department, an employee must retain the legal right and authority to carry
a pistol and any other firearm normally used by police officers. Conviction of any crime
that results in the loss of an employee’s rights to carry firearms will immediately
disqualify said employee from continued employment as a sworn police officer for the
City of Pelham.
In order to maintain and continue employment as a sworn police officer for the City of
Pelham Police Department, an employee must retain the legal right and authority to
access information from and through the Alabama Criminal Justice Information Center
and FBI NCIC computer systems. Conviction of any felony, or any other crime that
results in the loss of an employee’s right to access said computer systems, or a sustained
allegation of breach of the rules governing operation and access to said computer systems
which results in a decision by either the Alabama Criminal Justice Information Center or
the FBI NCIC to terminate an officer’s right and/or authority to access, operate or receive
information through said computer systems will immediately disqualify said employee
from continued employment as a sworn police officer for the City of Pelham.
___________________________________
Signature of Applicant
Date
(Sign as usually written. Do not use
nickname.)
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MM-DD-YYYY
AUTHORITY TO RELEASE INFORMATION
To Whom It May Concern:
I hereby authorize any Pelham Officer or other authorized representative of the Pelham
Police Department bearing this release, or copy thereof, within one year of its date, to
obtain any information in your files pertaining to my employment, military, credit or
educational records including, but not limited to, academic, achievement, attendance,
athletic, personal history, disciplinary records, medical records and credit records. I
hereby direct you to release such information upon request of the bearer. This release is
executed with full knowledge and understanding that the information is for the official
use of the Pelham Police Department. Consent is granted for the Pelham Police
Department to furnish such information, as is described above, to third parties in the
course of fulfilling its official responsibilities. I hereby release you, as the custodian of
such records, and any school, college, university, or other educational institution,
hospital, or other repository of medical records, credit bureau, lending institution,
consumer reporting agency, or retail business establishment including its officers,
employees, or related personnel, both individually and collectively, from any and all
liability for damages of whatever kind, which may at any time result to me, my heirs,
family or associates because of compliance with this authorization and request to release
information, or any attempt to comply with it. I am furnishing my Social Security
Number on a voluntary basis with the understanding such is not required by Stated statute
or regulation. I have been advised the Pelham Police Department will utilize this number
only to facilitate the location of employment, military, credit and educational records
concerning me in connection with this application. Should there be any question as to the
validity of this release, you may contact me as indicated below.
Full Name:__________________________ Full Name:
Signature
Typed
Social Security #:
Date of Birth: MM--DD--YYYY
Parent Guardian: (if required)_________________________
Current Address:
Phone Number:
Witness:________________________________________
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Date: MM--DD--YYYY
CITY OF PELHAM
POLICE DEPARTMENT
APPLICANT AFFIDAVIT OF ALABAMA P.O.S.T. CERTIFICATION AND
BASIC LAW ENFORCEMENT OVERALL COURSE AVERAGE GRADE
NOTICE TO APPLICANT: The information requested on this form is required in order to process
your request to be placed on the City of Pelham Police Department Eligible Candidates List. All
information requested must be provided or this request will not be processed. Providing the requested
information regarding an applicant’s Basic Academy Overall Course Average Grade is the responsibility of
the applicant. If there is some doubt regarding this grade, the applicant should contact the Alabama Peace
Officers’ Standards and Training Commission (A.P.O.S.T.) at 334-242-4045. The City will verify the
information contained on this form through A.P.O.S.T. prior to employment consideration. Any
discrepancies between the applicant’s records and the A.P.O.S.T. records must be resolved by the applicant
and A.P.O.S.T. prior to the addition of the applicant’s name to any police department Eligible Candidates
List. Records and grades maintained by A.P.O.S.T. will be considered official and final. Inaccuracies or
incorrect information provided by the applicant on this form will result in automatic disqualification from
consideration for employment and removal of the applicant’s name from any police department Eligible
Candidates List.
APPLICANT INFORMATION
Name:
Date of Birth: MM--DD--YYYY
Social Security Number:
Alabama P.O.S.T. Certification Number:
Law Enforcement Academy Attended:
Academy Session Number:
Dates of Academy Attendance:
Basic Academy Overall Course Average Grade:
%
Current Employer:
I,
, by signature herby affixed, do affirm the
accuracy of the information I have provided on this document, and further recognize that
any mis-statement, mis-representation or inaccuracy of this information required on this
document will automatically disqualify me from consideration for a position with the
Pelham Police Department and will result in the removal of my name from all Police
Department Eligible Candidates Lists. I further agree that a copy of the separate
“AUTHORITY TO RELEASE INFORMATION” form I have signed shall authorize
A.P.O.S.T. to release any and all information in their records pertaining to me.
Applicant Signature:_____________________________ Date: MM--DD--YYYY
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ATTENTION – THIS STATEMENT MUST BE SIGNED
During the application process you will be required to open for inspection, by a
supervisor of the Pelham Police Department, any and all social networking sites you are
currently and/or have previously utilized. This shall include any social networking site
you have visited for information only, added/made a post to or participated in the content
of the site in any form. This request will be used to determine suitability for employment
with the Pelham Police Department.
___________________________________
Signature of Applicant
(Sign as usually written. Do not use
nickname.)
MM-DD-YYYY
Date
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